Marine and Safety (Maritime Incidents) Regulations 2007
INVESTIGATION INTO PASSENGER INJURIES
HIGH SPEED PASSENGER VESSEL
“DEVIL JET II”
DERWENT RIVER, NEW NORFOLK TASMANIA
20th JANUARY 2012
MARINE AND SAFETY
TASMANIA
CONTENTS
FOREWORD
page 3
SUMMARY
page 4
SOURCES OF INFORMATION
page 5
THE VESSEL ‘DEVIL JET II’
page 6 & 7
NARRATIVE
page 8 & 9
COMMENTS
page 10 & 11
CONCLUSIONS & RECOMMENDATIONS
page 12 & 13
2.
FOREWORD
Inquiries and investigations into Marine Casualties occurring within Marine and Safety
Tasmania’s (MAST) jurisdiction are conducted under the provisions of the Marine and
Safety Tasmania (Maritime Incidents) Regulations 2007.
Incident investigation reports must be submitted to the Board of Directors of MAST.
It is MAST policy to publish such reports to increase the awareness of marine incidents so as
to improve safety at sea.
Copies of the reports can be obtained from:
Marine and Safety Tasmania,
PO Box 607,
Hobart TAS 7001
Or the web site:
http://www.mast.tas.gov.au
3.
SUMMARY
On Friday the 20th of January 2012 the high speed passenger vessel “Devil Jet II” departed
from the jetty at New Norfolk in Tasmania. The time was approximately 1400 hrs, there were
12 passengers on board and the skipper.
On the return run down river and approximately 5-10 minutes prior to the completion of the
30 minute trip, the skipper was negotiating a narrow passage between the river bank and an
exposed shingle bar when the port quarter of the boat contacted the bar. This contact caused
him to momentarily lose control and the boat swung to starboard and collided with the river
bank coming to a complete stop.
Due to the immediate de-acceleration of the boat, all passengers were thrown forward and all
were “shaken up”, however, two passengers suffered serious injury. A female passenger
suffered a compound fracture of her right wrist and a male passenger suffered a broken right
thumb.
After assessment of the passengers, the boat was re-floated and returned to the jetty where all
passengers were assessed and treated by ambulance officers.
4.
SOURCES OF INFORMATION

Incident Report from the Skipper/Operator.

Interview with Skipper on 24th January 2012.

Interview with vessel operator on 24th January 2012.

Interview with injured female passenger on 24th January 2012.

Phone interview with injured male passenger on 27th January 2012.

Safety Management Plan for “Devil Jet II” Certificate No: 17.

Police Report dated 20th January 2012
5.
DETAILS OF HIGH SPEED PASSENGER VESSEL “DEVIL
JET II”
Length:
Beam:
Draft:
Engines:
Hull materials:
Year built:
5.9m
2.34m
1.09m
One inboard 223kw petrol engine coupled to a Hamilton jet unit.
Aluminium monohull.
1996
Survey status:
2E for 12 passengers and 1 crew within all inland waters, rivers and
lakes but not more than 1 nautical mile from the shore.
Crew qualification requirements:
Skipper:
Coxswain Restricted with jet boat endorsement and workplace level II
first aid.
The vessel layout is an open monohull with three rows of open bench seats, the centre and aft
seats being able to seat 4 or 5 passengers and the forward seat being able to seat 3 passengers
and the skipper. The skippers’ seat is on the port side and helming is carried out from a seated
position.
Controls & Instrumentation:
Engine speed is controlled by a foot or ‘accelerator’ pedal and the jet unit is controlled by a
lever on the side of the vessel next to the skipper, the steering wheel is similar to a car
steering wheel. There is an engine speed instrument (rev counter) as well as various engine
monitoring instruments and alarms. Communication is by U.H.F. radio and mobile phone,
however, due to the topography of the Derwent River, the effectiveness of the mobile phone
can be somewhat spasmodic. In instances where the mobile phone is out of range, the UHF
radio is used to contact the booking office at the jetty. Communication to the passengers is by
word of mouth from the skipper.
All the bench seats face forward and are identical. They consist of a waterproof, vinyl fabric
which covers a firm cushion. Each seat has an aluminium tube of approximately 35mm
diameter welded behind it for the use of the passenger behind, there is also a similar tube
welded to the forward console. The forward leg area of the seats are covered in ‘all weather’
carpet which can also be used for the passengers to brace themselves using their knees.
Lifejackets are supplied to each passenger and worn by all on board for the complete duration
of the trip. Safety briefing of the passengers is carried after the boat departs the jetty during
the slow speed run to the up river bridge.
6.
Injured female passenger was seated in back row second from left (port) side, injured male
passenger was seated on the right (stbd) end of the middle seat.
7.
NARRATIVE
On Friday the 20th of January 2012 the high speed passenger vessel “Devil Jet II” departed
from the jetty at New Norfolk in Tasmania. The time was approximately 1400 hrs. There
were 12 passengers on board and the skipper.
As intended, the vessel did her regular tourist run of approximately 25 minutes proceeding
from New Norfolk and up the Derwent River and return. The purpose of the trip is to show
the passengers the scenery of the area, do high speed transits of various shallow water rapids
and carry out approximately 8-9 360 degree high speed ‘spins’ to add a ‘thrill’ aspect to the
trip. These types of manoeuvres can only be carried out on a shallow draft vessel fitted with a
water jet propulsion system.
The trip went as planned and the vessel was returning to New Norfolk in the tide affected part
of the river below the rapids. On the return run down river and approximately 5-10 minutes
prior to the completion of the 30 minute trip, the skipper was negotiating a narrow passage
between the south river bank and an exposed shingle bar when the port quarter of the boat
contacted the bar. This contact caused him to momentarily lose control of the vessel and the
boat swung towards the river bank and the starboard quarter collided with a tree. This
collision with the tree caused the vessel to swing sharply to starboard and the starboard bow
collided with another tree and the boat came to a complete stop. The speed of the boat prior
to contact with the shingle bank was approximately 35-40km per hour and the width of the
navigable river passage was approximately 8-10m.
Due to the immediate de-acceleration of the boat, all passengers were thrown forward and all
were “shaken up”, however, two passengers suffered serious injury. A female passenger
suffered a compound fracture of her right wrist and a male passenger suffered a broken right
thumb.
Immediately after the collision with the river bank, the skipper assessed the condition of his
passengers and asked those that were not injured to climb onto the river bank to allow the
injured and shocked passengers to lie down on the bench seats. The skipper also contacted the
jetty office and requested assistance from his father, the operator, who immediately drove to
the site of the incident in order to assist. Access to the river bank and boat was through dense
bush and it was decided that the boat should be re-floated and the passengers returned to the
jetty on the boat as to try and negotiate the steep bank would have been difficult and time
consuming.
Once the boat returned to the jetty, all the passengers were disembarked and were attended to
by ambulance officers who happened to be on the scene. The injured female passenger and
two of her children were taken by the ambulance to the Royal Hobart Hospital and the injured
male passenger and his family were driven to the hospital by his wife.
Of the 12 passengers, 7 were from the Hobart area and a family of 5 were holidaying from
Victoria.
8.
Once the passengers had all been attended to, the skipper and operator cancelled all further
trips for the day and checked the damage to the jet boat. As the boat had suffered some
structural damage, the survey section of Marine and Safety Tasmania (MAST) was informed
on the situation and an incident report was also completed and forwarded to MAST.
Subsequently, the boat was inspected by a MAST surveyor on the following day, Saturday
and the boat temporarily withdrawn from survey until such time as repairs could be carried
out. These repairs were completed on Sunday and the boat was re-entered into survey on
Monday 23rd January. Also, on Monday 23rd an incident investigator was appointed, by
MAST, to investigate the incident.
9.
COMMENTS
There are approximately 4-5 jet boats similar to ‘Devil Jet II’ operating in sheltered and
smooth waters in Tasmania. All operations are approximately the same whereby passengers
are taken to view interesting areas and 360 degree ‘spins’ are carried out to add a ‘thrill’
aspect to the trip. In all cases the skipper has to hold a certificate of competency as required
under the MAST issued ‘Manning Determination’ for the vessel, he/she also has to hold a ‘Jet
Boat Endorsement’ for the particular vessel. This endorsement is issued following a
prescribed training period on the vessel and is carried out within the area it is to operate to
ensure the holder of the endorsement is familiar with that operational area.
Marine and Safety Tasmania requires all operators of passenger carrying vessels to comply
with a Safety Management Plan (SMP). These plans require the assessment of risks relating
to the particular vessel, its operations and also the training and qualifications of the crew. In
fact, most SMPs for vessels of this size will usually be a document of some 20 pages.
(Example SMPs are available from MAST if required)
With regard to the SMP requirements for “Devil Jet II”, the crew qualifications and safety
requirements for the day in question were complied with and the SMP certificate of
compliance was current, as was the certificate of survey.
In the incident report, it was stated that the weather on the day was calm with little wind and
there was good visibility. It is not considered that the weather conditions were a contributory
factor to the incident.
The tidal conditions at the time are, however, considered to be a contributory factor to the
incident. A low tide of 0.23m was predicted for the port of Hobart at 1228 on the 20th
January. It is suggested by the operator, who is very familiar with the area, that the tidal
conditions at New Norfolk are about one hour behind Hobart and can also vary depending on
the release of water from the upstream Meadowbank dam. On the day in question, there was
no release of water from upstream and the low tide would have been between 1330 and
1400hrs. Consequently, the navigable section of the river in question was narrow and shallow
at the time of the incident at approximately 1420hrs.
Prior to departure from the jetty at New Norfolk, the passengers were issued with lifejackets
and a safety and information briefing was conducted once the vessel had departed from the
jetty. With regard to safety, the passengers were told not to stand up and to keep their arms
inside the boat at all times also, to hold on tightly and use their knees to brace themselves
against the seat in front. Following the incident, some passengers complained of bruised
knees and also carpet burns. It was also commented that the passengers seated in the back
row had difficulty hearing the safety briefing due to the noise from the engine behind them.
Following the initial investigations of this incident, the Safety Management Plan for the
vessel has been carefully reviewed and it is considered that some changes may need to be
made in order to try and prevent a similar incident occurring in the future.
10.
The skipper has also returned to the shingle bank, where the incident occurred and with
assistance, has moved some of the gravel away from the particular area in an attempt to
deepen and widen that particular section of the river.
During the various interviews, the investigator was also made aware that no phone calls were
made to request the assistance of emergency services, it just fortuitous that an ambulance and
ambulance officers were close to the jetty when the vessel returned with the injured
passengers. A short time later the local police officer attended the scene and spoke to the
injured passengers also, the skipper, at his own request, was tested for alcohol and the result
was zero.
During the process of the inquiry, the investigator went in the boat, with the skipper, to
inspect the area of the incident and to run through what had occurred, he also inspected the
boat and talked about the content of the information given during the safety briefing. From
this, two matters were of some concern:
 Most, if not all, similar vessels of this type are fitted with ‘grab bars’ which allow
the passenger to firmly hold on using their hand and opposed thumb. However, on
‘Devil Jet II’, the ‘grab bar’ is fully welded longitudinally which does not allow for
a complete grip on the bar.
 During the safety talk, no mention is made of the 360 degree ‘spins’ and these are
carried out without any prior warning to the passengers.
11.
CONCLUSIONS AND RECOMMENDATIONS
These conclusions identify the different factors contributing to the incident and should
not be read as apportioning blame or liability to any particular organisation or individual.
The high speed vessel “DEVIL JET II”, its purpose and operation.
Overall, the operation of the vessel is for the entertainment of tourists in order to show the
uniqueness of the environment, in this case the upper Derwent River and also the ‘thrill’
factor of travelling at relatively high speeds and the conducting of 360 degree ‘spins’. During
the 30 minute trip there is a certain obligation on the passenger, for their own safety, to brace
themselves and hold on as instructed by the skipper. However, it is the responsibility of the
operator and skipper to ensure that the requirements of the Safety Management Plan are
followed and adhered to and that the safe navigation of the vessel is planned and carried out
at all times. Furthermore, the safety and comfort of all passengers on the vessel is of
paramount importance.
In this particular incident, the river level was particularly low and there was little margin for
error in negotiating the narrow part of the river in question. It should be mentioned that by
their nature and design, jet boats are only capable of negotiating very shallow water when
they are ‘on the plane’ which means that a relatively high speed is required. In this instance,
the skipper misjudged where the deeper water was and after contacting the shingle bank,
momentarily lost control of the vessel. It is suggested that the whole incident occurred in
probably no more than 2-3 seconds in time.
Recommendations:

Passenger safety briefing – The owner and/or Skippers, responsible for the vessel
operation, to review the current safety briefing, given that this incident has occurred.
This review should consider all points but in particular the following:
1. Can the rear seated passengers hear and fully understand the briefing
above the engine noise or should the safety briefing be given prior to
passenger embarkation.
2. In the opinion of the investigator, given normal industry practise, the
passengers should be informed on the ‘spin’ procedures and informed
whenever a ‘spin’ is to be carried out. (this is usually done by the
skipper using an understood hand gesture)
3. A simple laminated safety card be produced to pictorially inform nonEnglish speaking passengers of the salient safety briefing points.
(Examples of this type of card are freely available within the industry)
Furthermore, that the amended safety briefing be scripted to ensure no salient points
are omitted irrelevant of the person responsible for giving the briefing. A copy of the
script to be forwarded to MAST for attachment to the vessel’s Safety Management
Plan. (SMP)
12.

Skipper and office personnel - Emergency Procedures – While the SMP covers the
actions to be taken in an emergency by both the responsible person in the office and
the skipper, these were not carried out following the incident under investigation. In
this regard, the production of a ‘check list’ should be promulgated for both the office
and the skipper. The SMP be amended to highlight the importance of adhering to the
emergency procedures and that copies of the ‘check lists’ be attached to the SMP
with additional copies (possibly laminated) kept close to hand in the office and on the
vessel.

Passenger ‘grab bars’ – While the adequacy of the existing hand holds did not
necessarily contribute to the injuries in this incident, it is considered that the survey
department of MAST should require the provision of passenger hand holds or ‘grab
bars’. These ‘grab bars’ to provide the passengers with a hand hold which allows
them to maintain a tight grip during the ‘thrill ride’ manoeuvres. This requirement is
mandatory on more modern vessels.

Periodic inspection of the operational area in the Derwent River – This incident
occurred at, or very close to, low water and the lack of navigable depth and space
was a major contributor to the incident. With this in mind, the operator and skipper of
‘Devil Jet II’ are to review Section 2 (d) of the SMP which requires “sufficient
navigable waters for the safe operation of the vessel”. This review to determine what
is considered safe navigable water and at what tidal level or conditions the operation
is to be suspended.

Approval of reviewed/amended Safety Management Plan – In the above
recommendations, reviews and amendments to ‘Devil Jet II’ SMP is required. It is
further recommended that once the operator/skipper has completed a draft of these
reviews, then the draft document and attachments be discussed with the designated
commercial Safety Management Plans auditor of MAST. This to be done in order
that all matters related to these recommendations for the prevention of a similar
incident have been addressed and are considered acceptable to MAST.
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13.